In response to a request by the Health Care Financing Administration (HCFA), the Institute of Medicine proposed a study to examine definitions of serious or complex medical conditions and related issues. A seven-member committee was appointed to address these issues. Throughout the course of this study, the committee has been aware of the fact that the topic addressed by this report concerns one of the most critical issues confronting HCFA, health care plans and providers, and patients today. The Medicare+Choice regulations focus on the most vulnerable populations in need of medical care and other services—those with serious or complex medical conditions. Caring for these highly vulnerable populations poses a number of challenges. The committee believes, however, that the current state of clinical and research literature does not adequately address all of the challenges and issues relevant to the identification and care of these patients.
- Definition of Serious and Complex Medical Conditions
- Copyright
- Acknowledgments
- Contents
- Executive Summary
- 1 Introduction
- CHARGE TO THE INSTITUTE OF MEDICINE
- SCOPE AND ORGANIZATION OF THIS REPORT
- DEFINITIONS OF SERIOUS AND COMPLEX MEDICAL CONDITIONS: ALTERNATIVES AND IMPLICATIONS
- Background
- Conceptual Overview—Serious and Complex Conditions
- Potential Operational Definitions and Criteria
- 2 Challenges in Health Care Delivery for Patients with Serious and Complex Medical Conditions
- QUALITY OF HEALTH CARE
- Patient Characteristics
- Provider Characteristics
- Patient Volume
- Health Care Delivery System
- ACCESS TO CARE
- HEALTH CARE COST CONTAINMENT
- Medicare and Medicaid
- Utilization Review and Management
- Care Management
- Screening and Risk Assessment
- Alternative Strategies for Cost Containment
- 3 Conclusions and Recommendations
- References
- Appendix A Workshop to Define Serious or Complex Medical Conditions
- CLINICAL IMPLICATIONS OF DEFINING SERIOUS OR COMPLEX MEDICAL CONDITIONS
- Disabled Populations
- Complexities of Patients with Cancer
- Serious and Complex Chronic Illness at the End of Life
- Example of a Population-Based Screening Intervention for Care Delivery Integration
- HEALTH CARE POLICY AND INSURANCE IMPLICATIONS OF DEFINING SERIOUS OR COMPLEX MEDICAL CONDITIONS
- Managed Care and Approaches to Regulation
- Implementation Strategies for the Medicare+Choice Regulations Concerning Serious or Complex Medical Care
- Serious or Complex Medical Conditions: Insurance Issues
- Appendix B Speakers Biographies
- Appendix C Workshop Agenda
- Appendix D Workshop Participants
- Appendix E Committee Biographies
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